Healthcare Provider Details

I. General information

NPI: 1093140170
Provider Name (Legal Business Name): DEREK VIGON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 ANDERSON RD
FALLS CHURCH VA
22043-1142
US

IV. Provider business mailing address

1750 ANDERSON RD
FALLS CHURCH VA
22043-1142
US

V. Phone/Fax

Practice location:
  • Phone: 310-467-5612
  • Fax:
Mailing address:
  • Phone: 310-467-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810006039
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: